Quality Measures

Clinical Measures

We use a set of best-practice indicators called Core Measures. These are proven actions that help to ensure good outcomes for our patients and are endorsed by the Centers for Medicare and Medicaid (CMS) for patients. Each of these actions are measurable, which enables us to track our success in applying the actions when caring for our patients.

Patient Experience

We want to ensure our patients always have the best experience possible whenever they interact with the UPMC Western Maryland team. Patients are selected randomly to participate in the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey.

We carefully measure the rate of application of these best practice indicators and compare them with the performance of others hospitals in Maryland and throughout the U.S. in order to make improvements in care.

UPMC Western Maryland focuses on areas identified by the CMS:

Venous Thromboembolism (VTE)

Venous Thromboembolism, or VTE, is when a blood clot forms in a deep vein in the body, such as in the leg. VTE is a common complication at surgery, and hospitalized medical patients – particularly those who have decreased mobility – are at risk for development of VTE.

Perinatal Care (PC)

Perinatal Care (PC) involves providing care to pregnant women and newborns. By providing care to pregnant women who follows best practices, hospitals and doctors can improve chances for a safe delivery and a healthy baby.

Emergency Department (ED)

Timely and effective care in hospital emergency departments is essential for good patient outcomes. Delays before getting care in the emergency department can reduce the quality of care and increase risks and discomfort for our patients with serious illnesses or injuries. Waiting times at different hospitals can vary widely, depending on the number of patients seen, staffing levels, efficiency, admitting procedures, or the availability of inpatient beds.

Acute Myocardial Infarction (AMI – Heart Attack)

Heart attack (also called an AMI–acute myocardial infarction) is a life-threatening event that happens when the arteries leading to the heart become blocked and the blood supply is slowed or stopped.

Heart Failure (HF)

Heart failure is a weakening of the heart’s ability to pump blood throughout the body. With heart failure, the body doesn’t get enough oxygen and nutrients.

Surgical Care Improvement Project (SCIP)

Scientific evidence indicates that certain measures are the best practice for the prevention of infections and other complications after many surgeries.

Additional information about Core Measures is available at Hospital Compare HHS GOV.

Patients are selected randomly to participate in the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey. This national survey asks patients how often different aspects of care were provided—never, sometimes, usually, or always. Since all hospitals across the country use the HCAHPS to measure patients’ perspective of care, the level of care provided at UPMC Western Maryland can be compared to the care provided by other hospitals in Maryland and the U.S.

Information about UPMC Western Maryland and other Maryland hospitals can be found in the Maryland Health Care Quality Reports.

Patients who reported that their nurses ALWAYS communicated well

Patients who reported that their doctors ALWAYS communicated well

Patients who reported on the responsiveness of the hospital staff

Patients who reported on their pain management

Patients who reported on the communication about medicines

Patients who reported on the cleanliness of the hospital environment

Patients who reported on the quietness of the hospital environment

Patients who reported on their discharge information

Patients who reported a positive rating of this hospital

Patients who reported on their willingness to recommend this hospital

Home Health Care is an important component of the patient care we provided and we are committed to ensuring that all of our patients receive quality care in their homes.

The Centers for Medicare & Medicaid Services (CMS) have developed a national survey that asks patients about their experiences with Medicare-certified home health agencies. This is also the survey that we send to patients who have used our home care services.

Since all Medicare-certified home health agencies use this survey, our patients can compare our level of care with other providers across the country. To learn more about how our home care patients’ experience of care compares to other providers, visit http://www.medicare.gov/homehealthcompare/search.html.

Patients who reported that their home health team gave care in a professional way.

Patients who reported that their home health team communicated well with them.

Patients who reported that their home health team discussed medicines, pain, and home safety with them.

Patients who gave their home health agency a rating of 9 or 10 on a scale from 0 (lowest) to 10 (highest).

Patients who reported YES, they would definitely recommend the home health agency to friends and families.